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1. I don’t often read articles with fMRI so this certainly was interesting. Any article that provides biological plausibility for what our clinical trials already are suggesting is a positive in my book. For application to clinical practice, this might be good evidence for starting a session with a longer aerobic activity in order to act as a window technique of sorts for harder functional or strength activities later.
The biggest issue with this article is the ecological validity though, as how many patients do we see that have FM/chronic pain and do not have a comorbid psychological diagnosis?
2. I think sometimes the traditional Borg RPE scale can be difficult for some patients to comprehend, but I do like the control it gives patients by telling them to raise/lower the difficulty as they see fit, just as long as they stay at a moderate effort level. I do know that some patients I have had with chronic pain get energized and motivated after a good day or a PT session and then go out and do too much activity, resulting in increased normal muscle fatigue and soreness that they might react negatively to. I think explicitly describing a “somewhat hard” difficulty might prevent this.
3. First off, I think my approach with these patients has definitely changed in the past 6 months. As we’ve talked about before, asking questions instead of always telling can make a big difference. I think I am more explicitly trying to identify where people fall in the stages of change and then providing cues/education to reach the next stage. A big part of it is just trying to find something that they will even consider doing and then riding that train. I think I’ve found the most success with setting small weekly goals.
4. When I get a referral for something like low back pain and the medical intake form also has FM marked on it for PMH, I typically try to do two seemingly opposing things 1) check the mostly negative connotations associated with that diagnosis at the door 2) realize that if my subjective and objective does rightly reinforce the initial clinical picture I have for this patient, that I will need to adjust my language/education and exercise prescription accordingly.
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1. What are your general thoughts on the study?
N=9, so take that for what it’s worth. I loved that the authors were able to visually demonstrate the difference in brain processing with the BOLD response graphs (they look like onions). Further evidence that we can show people the problem is also in the central nervous system, and not just painful tissue. As August said, these patients had few comorbidities and no psychological diagnosis. You can take this as a pro or con. Pro: these patients might have “true” fibromyalgia, and give a clearer picture of the disease. Con: not generalizeable, and not an accurate picture of a more typical FM patient with depression/anxiety. Would love to see this study re-done with just people with depression, or just anxiety, and see if the results differ!
2. This article seems like a great way to sell it to that hesitant patient. We all know looks at you like you are an alien when you ask them to try to do 10 minutes on the bike at level 6/10 intensity. Might be able to say well in this study they did 25 minutes, that’s our goal!
3. I am constantly changing how I attempt to do this with patients. It’s so individualized. As August said, asking questions to identify stage of change is key. Find their motivation. Develop their trust in you. Develop their confidence in themselves. Small steps.
4. I rarely see what you described, which is a patient who is here for XYZ pain/injury, who doesn’t relate it to their fibromyalgia diagnosis. I feel most of the time I see a patient who states this injury is worse because of the fibro. I first see if this person’s clinical presentation fits with their subjective/objective measures. If so, I often think about the state of their central nervous system and how it could reach to my wording about their injury and prognosis and may deliver my evaluation results a bit differently. If I see fibro on the intake form I always ask about it, and that leads me in the right direction. When were you diagnosed…how are you managing…what do you know about the disease… asking the right questions can help you determine how you are going to incorporate that diagnosis into your treatment and plan!
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I had to look up why left-handed people were excluded from the study. Apparently, lefties use both hemispheres for certain tasks that righties only use one hemisphere and can throw off results quite a bit. Sorry to the 10% of lefties with fibro this article doesn’t apply to. As already mentioned by Auggie-bear and Scott, it is rare to have a FM patient without psychosocial yellow flags. Though I feel this can be applied to most FM patients that would be one thing limiting its applicability.2.
It is extremely difficult to get a patient to buy into the use of aerobic exercise for pain. The benefit of using this article as a reference is: A) the parameters are simple and allow the patient to have some control and B) the pictures of the fMRI signals can be used as a visual aid assisting with potential buy in.3.
I have had one patient who I had bought into pain science and started seeing a conselor and was seeing significant improvements in pain and function. I know I talked to be about having a sensitized nervous system making manual therapy difficult.I talked to her about using 15-30 minutes of moderate aerobic exercise on the treamill (she liked walking) to lower her CNS sensitivity. This gave us a window to perform some manual therapy and allowed for specific therex to follow. This was a unique patient that I was able to get buy in at eval. I think what helped so much that day was relating her story to how she interpreted pain. She really seemed to “get it” when I could relate some pain science to her specific story.I have certainly failed a lot at getting buy in for these patients. But I think what was most helpful in this case was getting buy in early by relating her specific story to pain science. Once I had buy in and her trust, it opened more opportunities and her willingness to try what I had to offer.
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I’ll try to tease out if they think FM is related to their complaint and go from their. I feel like i Have a lot of patients that circle FM on the intake and write “possibly” or “not diagnosed” beside it. So, if its circled, I’ll ask them why they circled that and how they think their pain correlates with that. I’ll try to tailor the rest of my eval based on their response. Certainly, if they think it is related to their current complaint, it absolutely needs to be addressed based on their current belief system.-
Justin, I’d love to hear your experience if you do use this as a visual aid with a patient, as I feel like I would struggle to be concise with breaking down what is happening in those visuals and why it matters to that patient. You are a much more charismatic man than I though…
I do like your approach with directly asking about the FM from the intake form. Sometimes I wait to see if a patient makes a point of bringing it up on their own, especially if it is something like you mentioned where it is self diagnosed, but it might be better for everyone if it was addressed early.
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I have used the images a time or two from the research in JOSPT from 2013 using fMRI to show reductions in blood flow to pain areas of the brain following thoracic manipulation. My explanation was no more than, “the images show reduced activity in the pain areas of the brain following this technique”. Short and simple. Mainly because there is not a chance I could explain it in depth.
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I have found that using graded movement/exercise with less heavy pain education has been more effective than using videos and pain explanations with every patient that I think has FM or chronic pain. I think this article backs that up. Unless I am mistaken the participants do not receive any pain science education at all. This has been a shift in my treatment for these patients recently and is mostly due to finding myself talking in circles and having better results giving a very basic explanation of the body/brain being “over-protective” and the exercise providing a means to show the body that movement is not a threat to calm down the protective responses. I will also list to patients the benefits of regular CV exercise including increased blood flow to promote healing, release endorphins, and promote analgesic responses and not even provide any of the pain science education or analogies we have talked about before.
I find it difficult to use the Borg with everyone, but it is highly effective with patients that understand it. If the Borg isn’t going to work, I explain that I want the patient to find a CV exercise that they will do regularly and comfortably. We find a baseline distance or time and try to improve upon this week to week.
When I see patients with FM in their history or patients that have self-diagnosed themselves with something via Dr. Google I have these kinds of treatments in the back of my mind if they are not responding the way I would expect from traditional intervention, but I try not to jump the gun on throwing them in the chronic pain bucket.
Thanks for uploading this, it is a good article to keep on hand and was an interesting read. I love this stuff. -
Question for Katie/everyone: is this an area of pain science research that should be emphasized in physical therapy research? In a JOSPT from mid last year the intro opinion article made a point of talking about how our pain science research should focus on decreased costs of care and translating current research into actual clinical practice. Which is more important to advance our work as clinicians?
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